Health Insurance and You!

In the near future you may find your state legislature playing the role of the tooth fairy, protector of children’s gums and enemy of plaque. According to today’s New York Times, a new regulation calls for all Massachusetts children who attend preschool or daycare for more than four hours each day, or who eat lunch at school to brush their teeth in class.

In spite of the fact that parents may choose to opt out of the requirement, there is a very vocal outcry against the new mandate. Parent protesters are citing a variety of objections including concerns about spreading germs, swallowing fluoride, over-burdening caregivers and even wearing away tooth enamel from over-brushing. (see Mom’s Nation blog) Many parents are just shocked at the level of government intrusion into their children’s personal hygiene. What’s next? Mandating that children wash their hands after using the bathroom? Hmmm, sounds like a good idea to me. That would certainly be an effective way to prevent the spread of many illnesses. But, back to teeth.

Maybe parents would be less outraged if they knew about a study conducted by British medical researchers that found tooth decay reduced by 11-30% in under-privileged five year-olds who brushed at school. It’s an impressive finding. Or maybe they aren’t aware of the connections between oral health and coronary disease. Even if a child were a paragon of oral hygiene virtue, a little extra brushing after meals is not a bad thing. I would trust most daycare providers who manage to feed and change their charges without causing epidemics to assist children in brushing their teeth. Imagine the health complications, pain and expense saved by all that prevented tooth decay.

As for government reach – I recall similar outrage aimed at legislators who passed mandatory child car seat laws. But the early opposition evaporated and we are left with a law that has become second nature to us all. Who would think of putting a toddler in a car without first strapping him into an appropriate safety seat?

In a nation that spends over $100 billion on dental care (according to the Dep’t of Health and Human Services), it makes sense to train children early in health-sustaining habits. To Massachusetts parents I say: get over it. To everyone else I say: let’s watch to see the outcome of this practice and consider following in the steps of our neighbors to the East. What an easy way to help make our children healthier.

If you are buying health insurance for the first time, be sure to consider the entirety of your potential medical expenses.  It is easy to be wooed by entry-level premiums, but you may end up spending more in the end. 

For example, a healthy family of four may be offered plans with premiums as low as $3,200 and as high as $19,000 per year, but it is not clear that the bargain-basement policy is best.  In addition to considerations such as their overall risk tolerance and budget, this family needs to calculate its total out-of-pocket expenses.  Total out-of-pocket-expenses include deductibles, coinsurance, copays and any medical treatments and pharmaceuticals not covered by the insurance plan.  

When evaluating health care plans here are the variables to compare:

Premiums – your monthly payment to your insurer

Deductible – the amount for which you are responsible before the insurer begins coverage

Coinsurance – The percentage of your medical bills for which you are responsible after you’ve met the deductible

Copay – a flat fee you pay for doctor visits, emergency room visits and prescriptions

Out-of-pocket maximum – The maximum amount for which you are responsible in a given year.  After hitting this limit, the insurer pays 100% of approved expenses.

Services covered – for example, if you require mental health coverage and prescriptions or plan to get pregnant, make sure your policy covers these needs.

Providers in-network – make sure you like the doctors and hospitals in the plan’s network.  Out-of-network care can be very pricey.

Taxes – The effect on income taxes

Personal control – The degree to which you can control your own expenditures

The chart below compares two representative plans that might be available to a healthy family of four.  Both are actual plans available at GetInsured.com.  Plan A offers a low premium of $3,540 and has no coinsurance or copays once the deductible is met.  The deductible however is very high — $20,000.  In addition to these outlays, the family has to pay for its own prescriptions, mental health and other non-covered expenses.  Based on average medical expenses identified in the 2009 Milliman Medical Index , their expected out-of-pocket expenses could range from $7,000 to $27,000 depending on the medical expenses they actually incur.  Plan B has a premium of $12,216 and a deductible of $7,000.  It includes pharmacy coverage, but has 30% coinsurance and $40 copays for doctor visits.  The minimum expected outlay is about $16,000, and the maximum out-of-pocket should be $23,000.  Plan A could be either less expensive or more expensive than Plan B depending on the family’s health care needs for that year*.

Additionally, the buyers have to consider their tax burden. Many insurers now offer high-deductible plans with Health Savings Accounts (HSA’s).  Beneficiaries can place a designated amount of their salaries into a tax-free account from which they pay their medical expenses.  As with coinsurance rates, HSA’s motivate beneficiaries to save.  So, while you may end up paying more of your own medical bills, not only your premiums but also your income taxes may be lower.

Whether you are a first time buyer of individual insurance, are re-enrolling in a group plan or have had the same health insurance for years, it is worthwhile to take some time to consider the total amount you spend annually on health care.  Even if you are happy with your current situation, new products and new laws warrant that you conduct such a review.  Additionally, as you begin filing 2009 tax returns you want to make sure that you’ve asked for the appropriate deduction for medical expenses. 

GetInsured.com can help you choose from an enormous number of health plans, taking into account your total health care budget, so that you get the plan that is most cost-effective for your family.

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Assumptions are based on Milliman Medical Index, May 2009.  This index shows the average medical expenses for a family of four.   

*       Plan A assumes an average pharmacy expense of $2,484, plus $1,000 of mental health expenses.

*       Plan B assumes 30% coinsurance for average inpatient and outpatient expenses of  $7, 860 = $2,358, plus 16 doctor visits at $40 each, plus mental health expenses of $1,000.

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Since the first in-store clinic opened its doors in 2000, CVS, Walgreens, Target, Rite-Aid and of course, the big daddy of them all, Wal-Mart have opened more than 1,200 clinics, and served more than 3.5 million customers, according to the Convenient Care Association. After a decade of experience, and with near-universal coverage only a breath away, it is a good time to evaluate the success of in-store medical clinics, and to determine the changes needed in order for them to be an important channel in the health care delivery system.

There is no question that these clinics, staffed by nurse practitioners and physician’s assistants are enjoying some success. In a recent study published in the Annals of Internal Medicine, a publication of the Journal of American Medical Association (JAMA), researchers compared retail clinics with physician visits, urgent care centers and emergency room visits* for three common ailments – ear infections, sore throats and urinary tract infections. They measured patient costs, quality of care and whether or not patients received any preventive care, such as routine tests, as a result of the visit.

• Cost: The study found that retail clinics were less than two-thirds the price of physicians’ offices and urgent care centers.

• Quality: Quality of care was found to be essentially equal to physicians’ offices and urgent care centers.

• Preventive Care: Follow-up preventive care in retail clinics was similar to that received by patients in physician’s offices and urgent care centers.

* Emergency room visits for these common ailments were substantially more expensive, provided lower quality care and resulted in fewer preventive care follow-up tests.

But there are significant challenges to be met in order for retail clinics to serve both their shareholders and their communities.

• Adding services to compensate for seasonality: In- store operations excel with regard to colds and minor infections, most common during the winter months. But, they are struggling at other times of the year. This past summer, MinuteClinic, CVS Caremark’s clinic division, temporarily closed 89 of its 545 locations. To meet this challenge, MinuteClinic has dramatically expanded its services to treat non-seasonal conditions such asthma and diabetes management, vaccines for HPV and shingles, school and sports physicals and more.

• Managing criticism from doctors: Concerns voiced by medical associations include the threat to public health from clinics over-prescribing antibiotics, patients failing to maintain relationships with their primary care doctors and the inability of clinics to expand their offerings to non-episodic illnesses.

Retail clinics will have to use data such as the results of the JAMA study quoted above, to show patients and policymakers that physicians’ concerns are unfounded. For example, that study found that clinics prescribe antibiotics at the same rate as doctors and that patients receive an equal amount of preventive care. Similarly, data can be used to show that clinics are alleviating the burdens of treating non-urgent cases in emergency room and physician’s offices, allowing doctors to treat sicker patients.

• Serving the under-served: As providers of medical care, retail clinics are expected to benefit society, and should be accessible to needy populations. As publicly held corporations, they are required to return profits to their shareholders, and therefore tend to be located in more affluent neighborhoods. In fact, a separate report conducted by the Annals of Internal Medicine, showed that most clinics were not located in areas with greater medical need. The authors of the study conclude that operators of retail clinics must reconsider their location strategies in order to be an integral player in the future of health care delivery.

With health reform, we are expecting physician shortages and long waits for care. It seems we have no choice but to increase accessibility to non-emergency care. With a ten-year head start, retail clinics are positioned for a major role in our national health care delivery system.

What are your thoughts? Can clinics serve shareholders and patients? Do clinics erode the critical relationship between doctor and patient? Would you go to your local Wal-Mart for medical care?

Six months ago I wrote on this site that a congressional proposal for Health Care Reform would likely include exchanges at the state level, and that this was the most sensible way to go. In fact, today’s Senate bill outlines a plan for state and regional exchanges. But the House bill, which passed last month includes a plan for a national exchange. Over the next month, the two entities will have to come to a single recommendation on this issue. Here are the differences in the two bills regarding exchanges.

For an exhaustive and up-to-date comparison of the House and Senate Bills, go to the Kaiser Family Foundation site.

The issue of whether insurance is sold through one national or many local exchanges is incidental to the specifics of the proposed regulations. Medical loss ratios, premium differentials and rate adjustments can all be similarly legislated regardless of their distribution channels. Like Medicare and Medicaid, we can have a national program that is completely managed at the state level.

As the health care debate rages on in Washington I remain optimistic. I think that the legislature will succeed in improving access to health care for many people. But, I’ve said this before, it is imperative that each of us takes action now to sustain our own good health. We cannot and should not wait for legislation that can take years to implement. Here are some things every person should do to take control of his or her own health. The first three are well known, and I won’t expound on them, rather I will refer you to some informative sites. Points 4 and 5 are the keys to taking control of your medical future.

1) Eat right. eatright.org is the home site of the American Dietetic Association. The site provides informative articles and referrals to registered dieticians in your area. mypyramid.gov offers a personalized eating plan based on your height, age, weight and activity level.

2) Be active. The National Institute of Health (NIH) has an easy to use site that will help motivate you and get you moving in the right direction. If you haven’t exercised in a while, use good judgment; start slowly and check with your doctor.

3) Quit smoking. www.smokefree.gov, developed by the National Cancer Institute, is the best place to find online guidance and support services in your area.

4) Get insured. And get your family insured. Visit our site, www.getinsured.com or call our experts. We will work with you to find a plan that meets your needs. Everyday we are helping to insure people regardless of pre-existing conditions, tight budgets or complicated situations. Having insurance has a real affect on a person’s health. A recent Kaiser Family Foundation Study compared the health of people with insurance to those without insurance. The uninsured were significantly more likely to have no usual source of care, no preventive care, could not afford needed prescriptions and went without needed care. Ultimately insured people are healthier.

5) Have a Health Care Proxy. I know it sounds morbid and may be difficult to think about much less discuss with your loved ones. But, having a living will is the ultimate way to take control of your own health. Have the discussion. Write down your wishes. Be sure to designate someone you trust to make decisions on your behalf. For help you can go to www.engagewithgrace.org.

Here is a story I heard from a friend, an adult with a chronic illness. During an appointment with her Primary Care Physician last week she inquired about her flu vaccination status. He told her that she needed the seasonal flu vaccine and if possible, the H1N1 (swine flu) vaccine. He provided the seasonal flu vaccine, but said he did not have the H1N1 and had no idea about when or if it might come. The next evening, the doctor’s assistant called my friend and told her to go to his office right away for her H1N1 vaccine. He had just received a batch and was saving a shot for her.

The story made me think about how many people may be confused about all the information floating around about seasonal and H1N1 vaccines. I did my own informal research and found several sites helpful.

The CDC has two very informative and easy to understand sites, posted just a couple of days ago. The first one provides answers to frequently asked questions about seasonal flu, and the second provides answers for H1N1 related questions including who should and should NOT get the shot, where and when it is available and more.

I am convinced that getting vaccinated as soon as possible is a far better alternative to suffering from either flu. But not everyone is similarly inclined. In fact, I have heard that there are some celebrities advising people not to get a shot. Please, don’t listen to them, and for that matter, don’t listen to me. Ask a doctor or nurse whom you trust and get his or her opinion.

It’s Free…
Because the government feels strongly that this is a public health issue, it is paying for H1N1 vaccine. Other than a possible service charge that may be covered by your insurance provider it’s free. But even if you do have to pay a $25 fee to a clinic, isn’t that ultimately more cost effective than getting sick, paying for medicine and missing work?

…and it is Available
According to the CDC, the US government has procured 250 million doses of H1N1 vaccine, enough for everyone who wants it. Vaccine is being shipped to clinics every day. I looked online for a flu clinic near my home and found a list of locations, dates and phone numbers. Appointments are required and preference is given to people in high-risk groups. You can also go to www.flu.gov for a list of both seasonal and H1N1 flu clinics in your area and for the answers to most frequently asked questions.

Have you had trouble getting information? Will you get vaccinated? Do you have other sources of reliable information to share? Please share your story with us.

Wherever you go today, the topic of conversation is the new federal guidelines regarding mammograms and self-testing to detect breast cancer. This is a highly charged issue. After all, who doesn’t know someone who has had a brush with this ubiquitous disease? In addition to our reasonable fear of cancer, the discussion is taking place against the backdrop of health reform. Here are the two sides of the conversation.

Testing at 40
Many people are appalled and frightened by the new guidelines. The public has been taught since the beginning of time that women have to conduct monthly self-exams and have annual mammograms starting at the age of 40. We have been told that early detection saves lives. There seems to be no shortage of stories about young women who would have succumbed to the disease had they not found a tumor in a mammogram.
Furthermore, these new guidelines were issued by a federal agency, the United States Preventive Services Task Force, which according to the New York Times, arrived at the exact opposite conclusion after conducting studies only seven years ago. If your life, or the life of someone you love is at stake, why would you take a risk that a few years down the road they will reverse direction again?
Finally, because the recommendations were made by a federal agency people fear that any new government-influenced health care system will not pay for the tests. For more on this go to www.breastcancer.org

Testing at 50
The argument for postponing mammograms and foregoing self-exams seems coolly logical. The efficacy of mammography as a life-saving procedure has been the subject of debate for years. This is not the first study to suggest that mammograms do not save lives. In fact, researchers argue that mammograms cause harm because they force people to undergo an untold number of unnecessary, painful, costly and anxiety-creating procedures for cancers that may not be life-threatening.
Additionally, it is important to remember that the guidelines do not suggest that women who may be deemed at high risk of developing cancer should not be screened early. If a doctor finds that a patient is at risk either from medication, lifestyle, genetic testing or something else, a mammogram can be ordered regardless of the patient’s age.

Patients will be calling their doctors en masse over the next week seeking advice on this subject. You may want to be one of those callers.

Since 1985, many laid off workers have been protected by the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA allows workers the option of keeping the health insurance coverage they had while employed for up to 18 months, as long as they can pay the full amount of the premium.

According to the Kaiser Family Foundation, a not-for-profit foundation focusing on major health care issues, the number of people taking advantage of COBRA is not available. But one study implies that only 19% of eligible people were using COBRA in early 2009. Because employer-sponsored programs cover on average 83% of health insurance premiums, individuals who find themselves laid off have the double-edged burden of a fourfold increase in their health care costs and the loss of their incomes. It is not at all surprising that so few people choose to continue their coverage.

Last March, as a part of the economic stimulus package known as the American Recovery and Reinvestment Act of 2009 (ARRA), the federal government began offering substantial subsidies to help laid off workers pay their COBRA health insurance premiums for nine months. The package offers unemployed workers a 65% discount in the cost of their premiums. The program has proven effective in that Kaiser estimates that twice as many eligible people are keeping their health insurance benefits.

Those who were among the first to apply for the ARRA subsidies are coming to the end of their eligibility for the federal discount. And eligibility to begin receiving the discount is ending in two months. While congress is considering a bill to extend the subsidies, many people are finding themselves in a difficult situation. Should they stay on COBRA even though their costs may skyrocket, or should they seek other less expensive options?

An article by M.P. McQueen in today’s Wall Street Journal quotes one human resources expert who advises that participants should remain on COBRA if they can afford it especially if they or their dependents have any pre-existing conditions. For others, Mr. McQueen exploring their options by comparison shopping for private health insurance plans.

If you find yourself in such a situation, GetInsured.com is a great place to explore your options. Knowledgeable and helpful associates will listen to your situation and provide you with easy to use information about private health plans to meet your health needs as well as your budget.

Before you finalize your health plan decisions take the time to inquire about the extra benefits that may be available. Supplemental benefits may include dental expenses, vision care, Medicare supplemental insurance, alternative medicine and other health-related expenses not covered by your health insurance.

To be adequately insured you need to assess your medical priorities. Do you think you might need extra care? If there is a particular expense you are concerned about, make sure to ask about it.

Understanding the benefits you will receive with your new policy will not only help you determine what, if any supplemental products you need, but will also help you take full advantage of the benefits to which you are entitled. Find out if you are eligible for a discount on fitness club membership, glasses or physical therapy for example, and then be sure to use it!

I found this article funny and, while exaggerated, it shines a light on the inefficiency and lack of customer service in the health care delivery system. It was written by Jonathan Rauch and published on NationalJournal.com. Happy reading!

If Air Travel Worked Like Health Care
Fasten your seat belts — it’s going to be a bumpy flight.
by Jonathan Rauch

“Hello! Thank you for calling Air Health Care, the airline that works like the health care system. My name is Cynthia. How can I give you travel care today?”

“Hi. My name is Jonathan Rauch. I need to fly from Washington, D.C., to Eugene, Oregon, on October 23.”

“Yes, I’d be happy to assist you with that. It does look like we can get you on a flight on January 23 at 1 p.m. or February 8 at 3 p.m. Which would you prefer?”

“Neither. I need to be in Eugene on October 23. As in, the 23rd of October.”

“I’m sorry, we have nothing open on that date. You might try another carrier.”

“I suppose I’d better. Who has availability?”

“I’m afraid I have no way to know that. I have no way to look into their systems.”

“Who would know?”

“You can call them individually and ask. I’m sure you can find one.”

“Look, I don’t have time to call two dozen airlines. It’s important that I get to Eugene on the 23rd. There must be something you can do.”

“Well, it looks like maybe we could squeeze you in on October 26, if you don’t mind departing Washington Dulles at 5:35 a.m.”

“Good grief. All right, I suppose it will do.”

“I’m sorry, sir, we don’t use e-mail to transmit records and other personal or secure documents. We keep our records on paper.”

“Great, thank you, I’ll be happy to make that booking for you. That’s one flight from Washington Dulles to Chicago O’Hare on October 26. Will there be anything else?”

“Wait, hold on. Chicago? I’m going to Eugene. It’s in Oregon.”

“Yes, sir. The Eugene portion of your trip will be handled by a western specialist. We’ll be glad to bring you back from Chicago to Washington, though.”

“You mean I have to call another carrier and go through all this again? Why don’t you just book the whole trip?”

“Sorry, sir, but you do need to make your own travel appointments. We would be happy to refer you to some qualified carriers. May I have your fax number, please? Before I can confirm the booking, we’ll need you to fill out your travel history and send that back to us.”

“Cynthia, I have filled out my travel history half a dozen times already this year. I’ve told six different airlines that I flew to Detroit twice and Houston once. Every time I fly, I answer the same battery of questions. At least a dozen airlines have my travel history. Why don’t you get it from them?”

“We have no way we could do that. We do not have access to other companies’ records, and our personnel have our own system for collecting travel history.”

“But 95 percent of these questions are always the same. Don’t you know that every time I fill out one of these duplicative forms I increase the chance of error? Wouldn’t it make more sense to hold my travel information centrally, so that everyone could see the same thing?”

“Sorry, sir, we have no capability for that, and we do need to have your travel history at least two weeks before you fly.”

“I don’t suppose I could fill out these forms online?”

“No, sir. The forms are only about 30 pages, though. Did you have that fax number, please?”

“I don’t have a fax machine. No one faxes anymore. Just e-mail me the forms.”

“I’m sorry, sir, we don’t use e-mail to transmit records and other personal or secure documents. We keep our records on paper.”

“What century is this? You think paper is secure?”

“We do keep all your travel records on low-acid paper and in fire-retardant file drawers. When someone needs access to your records, we make a photocopy and put them in the mail. Or fax. How many items of luggage were you wanting to bring?”

“Two.”

“OK, good. We suggest you make luggage arrangements with Rapid Air Transport, though of course you’re free to use any luggage company you like.”

“Luggage company?”

“Yes, sir. You’ll need to arrange baggage transport. Would you like a phone number for Rapid, or would you prefer to find your own baggage company? I’m sure Rapid would be pleased to work with you. All you need to do is sign the Personal Travel Records Release form. Where would you like me to mail that?”

“Release form?”

“Yes, sir. You’ll need to sign and fax or mail that back to our Travel Records Department so that we can release your travel records to Rapid. Under the privacy rules, we’re not authorized to tell them when or where you’re flying without your written permission.”

“I suppose I couldn’t just e-mail you this permission, or grant it online?”

“No. Did you want a list of luggage carriers for your Chicago-Eugene leg?”

“Let me guess. Rapid doesn’t operate out West. I have to find a separate luggage company for the second leg.”

“Yes, sir.”

“And they’ll need more copies of all the same paperwork. And they’ll ask me all the same questions. And I’ll have to arrange to get my travel records to them by mail or fax. And I’ll repeat all this nonsense five or six separate times between here and Eugene, because the providers aren’t equipped to talk to each other and my records aren’t digitized and no two providers use the same system.”

“Yes, sir, that’s right! Did you have a preferred fuelist, or did you want a reference for a company to provide jet fuel for your flight?”

“Fuelist. That would be a fuel specialist, I suppose.”

“We can make a fuel arrangement for you, but please be advised that the fuelist’s charge will be billed separately and you will be responsible for it. We’ll need to know where to have that bill sent.

“May I have your flight-insurance information, please?”

“Millennium Travel Care, group number 068832, ID number RS-3390041B.”

“I’m sorry, sir, we’re not in Millennium Travel Care’s provider network.”

“You’re listed on their website. It says you accept Millennium.”

“We did until last week. If you like, you can pay out of pocket for your ticket.”

“How much would that be?”

“Yes, sir, I’ll be happy to get that price for you. That would be $17,885.70.”

“What? For a flight to Chicago? Does anyone actually pay that?”

“I’m sorry, sir, I wouldn’t know. I can tell you that different clients and insurers pay different rates. For individuals, the rate is $17,885.70.”

“Oh.”

“In a sane system, I would call an airline and it would give me a price for the whole trip, not just for one part of it.”

“Plus tax. And fuel.”

“Is anyone else cheaper?”

“Sir, again, I couldn’t tell you that. Carriers don’t have public rate sheets. Prices are privately negotiated, so there’s really no way you could comparison shop.”

“Oh.”

“Did you want to go ahead, then?”

“No. I DO NOT WANT TO GO AHEAD. I do not want to go anywhere! I want to jump off a cliff!

“This system is insane. It is fragmented to the point of incoherence. Record-keeping is stuck in the 1960s. Communication is stuck in the 1980s. None of the systems talks to the others. Everyone reinvents the wheel at every stage of the process. There is no pricing transparency.

“In a sane, modern system, I wouldn’t have to arrange each leg of my flight myself. I wouldn’t have to fax documents around, find and juggle multiple providers, fill out again and again what are essentially the same forms every time I use a provider.

“In a sane system, I would call an airline and it would give me a price for the whole trip, not just for one part of it. It would sell me a safe round-trip journey, instead a series of separate procedures. It would have back-office personnel using modern IT systems to coordinate my journey behind the scenes. The systems and personnel would talk to each other automatically. At the press of a button, once I entered a password, they would be able to look up my travel history. We’d do most of this stuff online.

“In fact, Cynthia, I would be able to arrange a whole trip with a single phone call!”

“Sir. Please. Calm down and be realistic. I’m sure the system can be frustrating, but consumers don’t understand flight plans and landing slots. Even if they did, there are thousands of separate providers involved in moving travelers around, and hundreds of airports, and millions of trips. Getting everyone to coordinate services and exchange information just isn’t realistic in a business as complicated as travel.”

“Yes. I suppose I’m dreaming.”

“Was there anything else I could help you with?”

“No.”

“My goal today was to provide you with outstanding service. Did I accomplish that?”

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